Hypospadias Objective Scoring Evaluation Research Articles

The application of the modified Snodgrass technique in hypospadias surgery.

We aimed to explore the effectiveness of the modified tubularized incised plate urethroplasty (Snodgrass Technique) in hypospadias surgery. A study was conducted on 50 pediatric patients with hypospadias treated in our hospital from May 2020 to May 2023. The patients were divided into two groups based on the condition of their urethral plate; 22 patients were included in the study group and 28 patients were included in the control group. The control group underwent the traditional Snodgrass technique, while the study group received the modified Snodgrass technique. The two groups were compared in terms of treatment efficacy, preoperative and postoperative 6-month Hypospadias Objective Scoring Evaluation (HOSE) scores, surgical data, and postoperative complications. The operation time for the study group was longer than that of the control group, and the intraoperative blood loss was less, but the differences were not statistically significant (p > 0.05). The success rate of surgery in the study group was 95.45% (21/22), compared to 71.43% (20/28) in the control group, showing a statistically significant difference (p < 0.05). The maximum urinary flow rate at 3 and 6 months postoperatively was significantly higher in the study group than in the control group (p < 0.05). The time to maximum flow (TQmax) and post-void residual (PVR) at 3 and 6 months postoperatively were significantly lower in the study group (p < 0.05). A total of 3 patients in the cohort developed urethral fistulas, all between 0.10 cm x 0.10 cm and 0.15 cm x 0.15 cm in size. By instructing the patients to apply pressure to the fistula during urination, all fistulas closed between 3 and 6 months postoperatively. The incidence of postoperative complications was 4.55% in the study group and 28.57% in the control group, a difference that was statistically significant (p < 0.05). The modified Snodgrass technique shows significant therapeutic effectiveness in hypospadias surgery, substantially increasing the success rate and reducing postoperative complications in pediatric patients, making it suitable for widespread application.

Evaluation of Tubularized Incised Plate Urethroplasty with Spongioplasty-Dartosoraphy Reinforcement in Pediatric Hypospadias: A Randomized Controlled Study.

The original description of tubularized incised plate urethroplasty (TIPU) was provided by Snodgrass in 1994. The results were significantly improved by several modifications. To decrease the incidence of complications, interposing a vascularized flap after tubularization of the neourethra is recommended. The extent to which the type of interposed tissue has a direct effect on the rate of complications and cosmetic outcomes after TIPU repair is considered the answer to the main hypothesis of this study. This prospective controlled randomized trial was conducted in the Department of Pediatric Surgery, Al-Azhar University, Cairo, Egypt, between May 2019 and May 2023. A total of 220 patients were included in this study. Patients were randomly assigned to either group A or group B. Group A included 110 patients who underwent TIPU with spongioplasty-dartosoraphy reinforcement. The other 110 patients (group B) underwent TIPU with dorsal dartos flap interposition, without spongioplasty. Complications developed in 34 of 220 patients (15.4%). In group A, complications developed in 11 of 110 patients (10.0%). In group B, complications occurred in 23 of 110 patients (20.9%). Although the fistula rate, glanular dehiscence, disruption, and meatal stenosis were not significantly different between the study groups, the skin necrosis rate was significantly lower in group A than in group B. The overall complication rate was significantly lower in group A than in group B. Also, the difference in the mean Hypospadias Objective Scoring Evaluation between the two groups was statistically significant. TIPU with spongioplasty-dartosoraphy reinforcement is an effective modification of conventional TIPU. This modification appears to reduce the rate of complications and yield better cosmetic outcomes.

Hypospadias Repair: Outcome and Objective Evaluation with Hypospadias Objective Scoring Evaluation (HOSE), Hypospadias Objective Penile Evaluation (HOPE) and Pediatric Penile Perception Score (PPPS) from Parents Perspective and Preference in COVID-19 Era

Introduction. Hypospadias is a common congenital abnormality. It may also be associated with other urogenital tract abnormalities. Literature has described more than 300 techniques being used. An objective evaluation is useful for attending doctor and parents to ensure both understands detection of complication and to assess post operative satisfaction from both sides are similar. Thus study sought to assess the outcome of hypospadias repair with objective scoring evaluation from parents’ perspective during COVID-19 era. Methods. This was a retrospective study of all patient post-hypospadias repair in Urology Unit, Hospital Universiti Sains Malaysia from January 2020 to December 2022 during the Covid-19 period. All patient medical records were reviewed. Data analyzed for demographic, surgical treatment, complications, and objective evaluation with HOSE, HOPE and PPPS questionnaire and parents preferred questionnaire to be used using Microsoft Excel for Windows 2003 and qualitative variables were presented as frequencies and simple percentages. Result. Hypospadias A total of 21 pediatric patients operated. The mean age during surgery was 7.2 years old. Distribution of glanular 6 patients, distal 3 patients and majority are proximal hypospadias with 12 patients (57.2%). Proximal hypospadias, 6 proximal penile and 6 penoscrotal. Single stage repair 18 patients and 2 patients had scrotoplasty performed and 3 patients had two stage repairs. Majority of single stage surgery performed was TIP and two stage repairs done with Bracka’s technique. Overall mean follow-up time 16.78 month. Three patients had UCF with 14.3%. Questionnaire with HOSE showed mean score 14.38. The HOPE questionnaire showed mean score of 54.71 and PPPS mean score was 10.2. Majority of parents preferred to use HOPE with 66.7% as compared to HOSE 14.3% and PPPS 19%. Discussion. This study has a small sample size possible due to very low rate for hypospadias in Malaysia and Covid-19 pandemic. Due to the pandemic, European Association of Urology recommended for repair before 18 months. However, if done after 2 years old showed significant predictor for complications. Validated questionnaires are useful and comparable to assess objectively both functional and patient satisfaction. However, HOPE might overestimate quality of cosmetic outcome compared with PPPS. Despite many available evaluation scoring systems were compared, reports show similar conclusions with none being more superior. Conclusion. Hypospadias requires complex surgery and complications are expected but should be within acceptable standards. In COVID-19 era, hypospadias repair had to be delayed and causes negative impact to patients. Despite many various techniques available, surgeons experience and technique preference are very important. There is no evaluation score more superior than another. It has its advantages and disadvantages. Parents satisfaction and functional outcome after repair should be routinely done for objective assessment.

Hypospadias with Intact Prepuce: A Spectrum of Anomalies and their Reconstruction.

The aim of the study was to perform a detailed analysis of the clinical characteristics of megameatus with intact prepuce (MIP) and to audit our results of reconstructive surgeries on MIP. Design: Retrospective analysis. Setting: Pediatric surgery department of tertiary level. Subjects, methods: Hospital records and pictures of MIP operated over a 9-year period. Age, size of penis, circumcised or not, shape of glans, external urethral meatus (EUM), urethral plate (UP), chordee, distal urethra, reconstructive surgery, and complications were analyzed. Postoperative result was objectively assessed by Hypospadias Objective Scoring Evaluation (HOSE). Twelve of 254 hypospadias were MIP (incidence = 4.72%). The mean age at operation was 38.25 months (12-87 m). Patients sought circumcision or surgical correction of anomaly. Two patients were precircumcised. MIP was coronal 7, subcoronal 3, and glanular 2. Meatus was wide in 10 and normal in 2. Glans penis was wide in 9 and conical in 3. UP was wide (9), moderately wide (2), or narrow and shallow (1). In two cases of wide deep UP, distal septum was present. Distal urethra was nondilated in all but 1, which had megalourethra. Reconstructive surgery was Tubularized Urethral Plate Urethroplasty (7 cases) or classical Snodgrass (Tubularised incised plate urethroplasty (TIPU), with superimposed vascular dartos flap (5 cases). The megalourethra underwent partial excision and TIPU. Distal UP-septum was incised. Urethral injury (2 cases) and UP injury (1 case) were intraoperative complications. One postoperative complication (ventral glans necrosis) resulted. The mean follow-up period was 4.79 months (1-12 m). In the postoperative follow-up, 11 (92%) had HOSE score 14-16, whereas one had HOSE 13. Some hypospadias cases which have intact prepuce have no megameatus; hence, they cannot be termed MIP. All cases of hypospadias having intact prepuce can be covered by the umbrella term "Hypospadias with Intact Prepuce (HIP);" MIP is a large subgroup under HIP. HIP presents with a spectrum of anomalies of glans, EUM, and UP. Repair by tubularization of UP without or with midline incision gives excellent results.

Outcomes of double-breasted spongioplasty as additional tissue coverage in tubularized incised plate urethroplasty

BackgroundModern hypospadiology is constantly developing new ideas to improve functional outcomes. Tubularized incised plate urethroplasty (TIPU) with neourethral covering by vascularized tissue (dartos flap, corpus spongiosum) is presently the most common procedure performed. Aim of this study was to evaluate the effectiveness of double-breasted spongioplasty (DBS) as additional tissue coverage in TIPU by comparing it with TIPU without spongioplasty. MethodsWe conducted a prospective comparative study from September 2022 to October 2023 on 120 midshaft and distal hypospadias cases aged 1 to 12 years. Group A (n = 60) underwent TIPU without spongioplasty; Group B (n = 60) underwent TIPU with DBS. Pre-operative patient parameters were categorized according to Glans-Meatus-Shaft (GMS) Score. Follow-up was 4 months to one year. Complications like urethrocutaneous fistula (UCF) and meatal stenosis (MS) were recorded. Functional outcomes were assessed using Hypospadias objective scoring evaluation (HOSE). ResultsAverage age was 5.68 ± 2.26 in group A and 6.40 ± 2.10 in group B. Group A had mean GMS 5.32 ± 1.09; Group B had 5.45 ± 1.12 (p = 0.49). In group A, 4 (6.66 %) had MS, 5 (8.33 %) had UCF; in group B, 5 (8.33 %) had MS, 2 (3.33 %) had UCF (p > 0.05). Dorsal plication for ventral curvature was avoided in 7 patients after DBS. Surgeon evaluated mean HOSE was 14.73 ± 1.87 in Group A and 15.40 ± 1.26 in B (p = 0.02); in group A, 83.33 % while in group B 95 % cases had acceptable HOSE (≥14) (p = 0.04). ConclusionDouble-breasted spongioplasty in TIPU has better functional outcomes when compared with TIPU without spongioplasty and may correct ventral curvature of mild to moderate severity. Level of evidenceLEVEL II.

Post-pubertal functional outcomes of one-stage anatomical reconstruction of the corpus spongiosum, bulbo-spongiosus muscle and dartos in 46 children with proximalhypospadias

Anatomical studies of hypospadias show failure of zipping-up of histologically normal urethral plate and corpus spongiosum. With the commonly utilized substitution urethroplasties for proximal hypospadias, a reconstructed urethra of just an "epithelial-lined tube" with no spongiosal support, is apt to long-term urinary and ejaculatory dysfunctions. We completed a one-stage anatomical reconstruction in children with proximal hypospadias whenever the ventral curvature could be reduced to <30° and evaluated the post-pubertal outcomes. This is a retrospective analysis of prospectively maintained data on one-stage anatomical repair of proximal hypospadias between 2003 and 2021. In children with proximal hypospadias, the corpus spongiosum, bulbo-spongiosus muscle (BSM), Bucks', and Dartos' layers of the shaft were anatomically re-aligned prior to assessing the ventral curvature visually. When the curvature was >30°, the urethral plate was divided at the glans for a 2-stage procedure, and those patients were excluded from the study. Otherwise, the anatomical repair was continued (this series). The Hypospadias Objective Scoring Evaluation (HOSE) and the Paediatric Penile Perception Score (PPPS) were used for post-pubertal assessment. Prospective records provided details of 105 patients with proximal hypospadias who had complete primary anatomical repair. The median age at surgery was 1.6 years, and 15.9 years at the post-pubertal assessment. Forty-one (39%) had complications that necessitated re-operations. Thirty-five (33.3%) patients had complications involving the urethra. For fistula and diverticula, eighteen cases required only one corrective procedure, while one required two. Other 16 patients required an average of 1.78 corrective operations for severe chordee and/or breakdown, with 7 requiring Bracka's 2-stage procedure. Fifty patients (47.6%) were over 14 years old; 46 (92.0%) had pubertal reviews and scoring, while four were lost to follow-up. The mean HOSE score was 14.8/16, and the mean PPPS score was 17.8/18. Five patients had residual curvature of >10°. 17 and 10 patients, respectively, were unable to comment on glans firmness and ejaculation quality. During erections, 26/29 (89.7%) patients reported a firm glans, and 36/36 (100%) reported normal ejaculations. This study proves the need for reconstruction of normal anatomy for normal post-pubertal function. In all proximal hypospadias, we strongly recommend anatomical reconstruction (zipping up) of the corpus spongiosum and BSM. When the curvature can be reduced to <30°, a complete one-stage reconstruction is possible; otherwise, anatomical reconstruction of the bulbar and proximal penile urethra is recommended, reducing the length of the epithelial-lined substitution tube for the distal shaft and glans.

Dorsal inlay inner preputial graft repair versus ventral-only preputial graft repair in primary distal penile hypospadias with narrow urethral plate.

Tubularized incised plate (TIP) is the most common technique used for distal hypospadias repair with good outcome but with a high rate of urethral stricture. Inner preputial-free graft can be used as an inlay graft in the incised area of the narrow urethral plate, also can be used as an onlay graft for urethroplasty in hypospadias repair to avoid this complication. A comparative prospective randomized study was conducted on two groups of hypospadias patients with narrow urethral plate. Group A: dorsal inlay inner preputial graft repair was performed (grafted TIP [G-TIP]) and Group B: ventral onlay preputial graft repair was performed. The assessment of outcome and hypospadias objective scoring evaluation (HOSE) score was done at 2 weeks and 6 months. Group A included 55 patients for whom dorsal inlay inner preputial graft repair was performed (G-TIP), and Group B which was planned to be conducted on 55 patients using onlay preputial graft (onlay graft) but was terminated after 15 cases due to high failure rate (33%). Group A showed better success rate 96% and better HOSE score (score 16) at 2 months and 6 months 83.6% and 88.2% versus 26.7% and 33.3% in Group B. Postoperative complications showed a statistically significant difference; glans dehiscence (3.6% vs. 40%), wound infection (1.8% vs. 33.3%), and skin sloughing (3.6% vs. 26.7%) in Groups A and B, respectively. G-TIP is a good technique for the management of distal hypospadias with narrow urethral plate with good success rate, cosmetic outcome, and with less complications compared to onlay graft.

Distal hypospadias repair: Comparative study between snodgrass and transverse preputial onlay flap

Distal hypospadias repair has several operative strategies such as tubularized incised plate (TIP); Transverse preputial onlay flap (TPOF) and Modified Mathieu Procedure. The aim of our work is to compare between TIP and TPOF techniques in the outcome. We conducted this comparative study on 66 patients with different types of distal hypospadias divided in two groups A and B for TIP and TPOF respectively. We reported outcome and complications for both TIP and TPOF repair. Our results revealed mean operative time was significantly higher in group B (123.1±6.8min) than in group A (93.73±3.9min, P value<0.001). Postoperative urinary fistula was reported in group A (15.2%) while no fistula in group B (p value=0.05). The vertical slit appearance of meatus was better in group A (54.5%) than in group B (24.2%, P value 0.023). As regard to hypospadias objective scoring evaluation (HOSE) (Summary Figure) the meatal shape score was higher in group A (1.55±0.51) than in group B (1.24±0.44, p value=0.0l), the urinary stream score was significantly higher in group A (1.82±0.39) than in group B (1.97±0.17, p value=0.04) and the urinary fistula score was significantly higher in group A (3.79±0.60) than in group B (4±0, p value=0.04). Complications are more common after TIP than in TPOF. As regard the meatus shape, the naturally looking vertical slit like meatus was achieved more in the TIP than in TPOF. We advocate further studies with a large number of patients with a long follow up period. TPOF is a great option to consider in cases of distal hypospadias because it is an effective technique for primary distal hypospadias repair with a good cosmetic outcome and a low associated complication.

Assessment of postoperative cosmetic outcomes of distal form hypospadias repair with the Hypospadias Objective Scoring Evaluation (HOSE).

Aim A standardized assessment for the optimal repair of hypospadias remains elusive. The aim of this study was to assess a postoperative cosmetic outcome of hypospadias repair using a validated questionnaire, Hypospadias Objective Scoring Evaluation (HOSE). Methods During the period between January 2016 and May 2019, 40 patients who underwent hypospadias repair were identified and they agreed to a follow-up using the HOSE. Distal hypospadias repairs underwent a cross-sectional assessment of the cosmetic outcome. Cosmetic assessment was performed by an independent physician using the HOSE scoring system. Results The native meatus was coronal in 10 (25%), subcoronal in eight (20%), and distal penile in 22 (55%) patients. Mean followup was 35.90 months (SD ±29.58) postoperatively (range 12-162 months). Complications occurred in one (2.5%) patient. Out of 40 uncomplicated repairs, 39 (97.5%) were satisfactory. A vertical slit-like meatus located at the distal glans was created in 33 (82.5%) boys, and at the proximal glans in seven (17.5%). The urinary stream was single and straight in 39 and spray in one patient. A straight erection was observed in 39 (97.5%) boys. The median HOSE score was 16 (range 12-16). One patient had a small, single coronal fistula. The technique used included tubularised incised plate urethroplasty. Conclusion The HOSE score is simple, easy, non-invasive and non-expensive tool for objective assessment of long-term outcomes of hypospadias repair.

Small Intestinal Submucosa for corporeal body grafting in patients with proximal hypospadias and severe chordee: Long term follow-up assessing erectile function and genital self-perception

Proximal hypospadias and severe ventral chordee are often challenging to repair. To preserve penile length in chordee repair, Small Intestinal Submucosa (SIS) corporal grafting is often performed with potential long-term complications including recurrent curvature and erectile dysfunction (ED). There is a paucity of data evaluating sexual function in mid, late and post-pubertal patients. We aimed to assess long-term outcomes of genital self-perception and erectile function in mid, late and post-pubertal patients who underwent single-layer (1-ply) SIS corporal body grafting for correction of severe chordee. Patients with proximal hypospadias who underwent correction of severe chordee using SIS grafting between 2001 and 2015 were retrospectively identified. Patients were evaluated for erectile and sexual function using the modified erection hardness score (mEHS) and the modified sexual health inventory for men (mSHIM). Perceived function and straightness were measured with Hypospadias Objective Scoring Evaluation (HOSE). Penile self-perception was assessed using the Pediatric Penile Perception Score (PPPS). Results were compared to an age-matched healthy control group. Categorical variables were analyzed using Fisher's exact test, and continuous variables using paired and unpaired t-test and ANOVA. Nineteen patients with proximal hypospadias who underwent correction of severe chordee using SIS grafting and 18 controls participated in the study with a median age of 17 years for both groups. In the mEHS, 12 (63.2%) hypospadias-patients and 14 (87.5%) controls rated their erections as completely hard and very rigid. In the mSHIM, 1 (5.2%) hypospadias-patient was classified as having moderate ED. A total of 16 hypospadias-patients (84%) and 16 controls (88.9%) reported being very satisfied or satisfied with the straightness of their penis. No significant difference was observed in the mEHS, mSHIM and PPPS between groups (p<0.05). The straightness of the erection was rated lower by participants, than by the pediatric urologist. In the HOSE, 12 (63.2%) hypospadias-patients and 16 (88.9%) controls obtained an acceptable score. Our findings indicate favorable long-term outcomes in ED and genital self-perception; only 5% of our population reported having a mild-moderate to moderate presentation of ED, and there were no reports of severe ED. The overall PPPS satisfaction rates were statistically similar for the control and hypospadias groups. The small sample population limits the significance of our findings. Corporal body grafting with 1-ply SIS suggests positive long-term outcomes in genital self-perception and erectile function, with mid, late and post-pubertal patients who underwent hypospadias repair having comparable results to age-matched healthy controls.

Mathieu vs urethral plate tubularization in circumcised Megameatus intact prepuce repair: A prospective randomized comparative study.

The objective of this study is to evaluate and compare urethral plate tubularization vs Mathieu in circumcised Megameatus intact prepuce (MIP) repair. Many techniques were described for MIP, which account for 5% of hypospadias cases and usually diagnosed at time of, or even after circumcision. Forty-six circumcised MIP cases were prospectively enrolled in this prospective study, which was carried out in April 2017 and March 2020. Patients were randomly allocated into two groups. Group one operated by simple urethral plate tubularization and group two by the Mathieu technique. Hypospadias objective scoring evaluation (HOSE) scores, success rate, operative time, and the need for relaxing incision or scrotal flaps for skin closure were compared. Forty-three circumcised cases (22 in group one and 21 in group two) completed at least 6 months of follow-up. Ages ranged from 12 to 39 months (mean 18.06 6 6.35) in group one and from 10 to 32 months (mean 19.5 6 7.14) in group two. There was no significant difference between cases with accepted outcome based on HOSE scores (14) of the two groups (P value ¼ .942). Three fistulae and one meatal stenosis were the complications in group one (18.2%). In group two, two patients complicated with fistula (9.5%) (P value ¼ .674). Significant differences were present only in the operative time (P ¼ .001) and in the need of relaxing incision or scrotal skin flaps (P ¼ .012) both were more in group two. Mathieu and tubularized incised plate urethroplasty both are good options for circumcised MIP repair.

Comparing Mathieu and Tubularized Incised-Plate Urethroplasties for Repairing Distal Penile Hypospadias: A Single-Center Experience with Long-term Outcome

Background: Hypospadias is a congenital anomaly on the penis, in which the meatal orifice opens ventrally and proximal to the tip of the penis. In this regard, two common treatment methods are tubularized incised-plate urethroplasty (TIP) and the Mathieu incised-plate (MIP) technique. The present study aimed to compare the early and long-term outcomes of TIP and MIP among patients with distal penile hypospadias. Objectives: The study was also to evaluate the postoperative functional outcome of hypospadias over a long-term follow-up. Methods: Fifty-nine patients were randomly selected and assigned to two groups (TIP (n = 31) and MIP (n = 28)). Demographic information, preoperative findings, and postoperative complications were collected from the two groups. The Hypospadias Objective Scoring evaluation (HOSE) questionnaire and uroflowmetry were obtained to evaluate the long-term outcome of hypospadias repair. Results: The success rates of the surgical TIP and MIP techniques were 71.0% and 82.1%, respectively. Postoperative complications in the TIP group were three (9.7%) distal UCF and four (12.9%) meatal stenosis. In the MIP group, two (7.1%) and three (10.7%) patients suffered from distal UCF and meatal stenosis, respectively. Moreover, 89.3% of the patients in the MIP group and 80% of the patients in the TIP group had acceptable HOSE. Regarding the uroflow rates in the MIP group, 12% and 58% of the participants were below the 5th percentile and above the 25th percentile, respectively. Concerning the uroflow rates of TIP, 32% of the patients were below the 5th percentile, and 18% of the participants were above 25th percentile. Conclusions: Although there have been some reports on the superiority of TIP, we found these two techniques at approximately equal levels with a slightly higher success rate for the MIP regarding the early outcomes. With the exception of the long-term outcomes in cosmetic and functional evaluation, MIP is superior to TIP.

Dressing or Not after Tubularized Incised Plate Urethroplasty

Background: Many surgical techniques, as well as dressing models, were identified in the treatment of hypospadias. There are many publications in the literature that are the result of the effort to find the ideal dressing after hypospadias surgery. The dressing has some benefits; however, it has some adverse effects. The present study aimed to discuss outcomes of the patients who have been operated through the tubularized incised plate urethroplasty (TIPU) method and followed with and without dressing postoperatively. Methods: Patients operated on through the TIPU method between March 2015 and August 2019 were reviewed retrospectively. The patients were divided into two groups, dressing and undressing. Preoperative hypospadias severity was evaluated according to the Glans-Urethral Meatus-Shaft (GMS) scoring method. The care results of the patients were recorded. Postoperative outcomes were compared according to the Hypospadias Objective Scoring Evaluation (HOSE) scale, and statistical analyses were conducted. The results of both groups were compared statistically. Results: One hundred and nineteen patients were divided into two groups: dressing (n = 56) and nondressing (n = 63). The patients’ average age was 3.54 ± 2.97 years in group 1 and 3.50 ± 3.01 years in group 2 (p = 0.940). There was not any statistically significant difference between the two groups for demographic data. Minimal bleeding had stopped in three patients in the nondressing group spontaneously before discharging. No severe edema or hematoma, which might have concerned the parents, appeared. Two (3.5%) and 3 (4.7%) patients underwent a maximum of three urethral dilation sessions in dressing and nondressing groups, respectively (p = 0.556). We found no significant difference between groups in the comparison of preoperative GMS and postoperative HOSE scoring. Discussion: The most important limitation of the study is that it is retrospective. Pre- and postoperative scoring systems are objective. The data obtained in the literature show that surgeons prefer to apply dressings commonly after the TIPU technique. Advantages and disadvantages of dressing are mentioned in the literature. Even if the paradigm is dressing in hypospadias surgery, according to the results of our study, dressing may not affect the functional and cosmetic results of TIPU repair. Conclusion: Postoperative functional and cosmetic results of TIPU in hypospadias appear to be independent of dressing. However, the results must be supported by further research.

Glans Preservation in Surgical Treatment of Distal Urethral Strictures With Dorsal Buccal Mucosa Graft Onlay by Subcoronal Approach

To describe dorsal onlay buccal mucosa graft urethroplasty technique by subcoronal approach and glans preservation in distal penile urethral strictures with fossa navicularis involvement and to report safety, effectiveness, and cosmetic outcomes. Retrospective review of a prospective database of patients treated at Hospital Italiano de Buenos Aires between January 2011 and December 2019. Main surgical steps: ventral subcoronal incision, dorsal dissection of glandelar urethra until piercing the tip of the glans, dorsal urethrotomy, and graft transposition. Low urinary tract symptoms, uroflowmetry, and urinalysis were assessed at follow-up. Simplified International Index Erectile Function and Hypospadias Objective Scoring Evaluation were applied 1 year after surgery. Sixteen patients with a median age of 56.5 years (IQR 35.7-66.7) were included. Median stricture length was 5.5 cm (IQR 4-8.7). In 3 patients, Clavien-Dindo grade I-II complications were reported. At 1 year, median peak flow was 18 mL/seg (IQR 12.7-27.4) and median mean flow 7.8 mL/seg (IQR 6.1-9.9). At 41.5 months follow-up (IQR 13.2-74), all patients were stricture free and had no changes in erectile function. Hypospadias Objective Scoring Evaluation score ≥14 points was achieved by 14 patients (87.5%). For treatment of distal penile urethral strictures with fossa navicularis involvement, dorsal onlay buccal mucosa graft by subcoronal approach and glans preservation is a feasible technique with excellent functional outcomes, minimal complications, and substantial cosmetic results.

Does intraoperative penile tourniquet application during hypospadias repair affect the patients and surgeons reported outcomes? A randomized controlled trial

Hemostasis aimed to maintain the bloodless surgical field for better exposure for the surgeon. There are no trials regarding the impact of hemostasis techniques for hypospadias surgery on surgeon satisfaction and patients' reported outcomes. Application of penile tourniquet is a common practice in hypospadias surgery that aims at reducing blood loss and improving visualization. Yet, scarce data exist on the effect of penile tourniquet on hypospadias repair outcomes. To evaluate the safety and efficacy of restraining penile perfusion using a tourniquet in hypospadias repair on the surgical outcome, also surgeons and patients reported outcomes. To evaluate the effect of penile tourniquet application on hypospadias repair outcome and surgeon's satisfaction with intraoperative hemostasis. In this single-blinded randomized controlled trial, a total of 110 children with distal hypospadias amenable for TIP repair were assigned to hypospadias repair with or without intraoperative application of a penile tourniquet. Surgeries were performed by a junior (2-5 years of experience in TIP repair) or a senior pediatric urologist (with >5 years of experience). Intraoperative blood loss, the number of times bipolar diathermy was used, hemoglobin deficit, and operative time were compared. Surgeon's satisfaction with intraoperative hemostasis was evaluated using a 4-tiered questionnaire. Patients were followed up for a minimum of one year. Complications and readmission rates were compared. The patient-reported outcome of hypospadias repair was assessed using the hypospadias objective scoring evaluation (HOSE). Baseline patient demographics and hypospadias characteristics were comparable between the study groups. Bipolar diathermy was more often used in the non-tourniquet group (mean±SD=5.7±1.8 times vs. 6.7±1.9 for the tourniquet group; p=0.007). Also, the operative time was longer in non-tourniquet group [mean=54.7±14.9 vs. 60.8±12.5min (p=0.028)]. Junior surgeons were more likely to be satisfied with hemostasis when a tourniquet was used (97.4% vs. 79.5%, p=0.02). Postoperative complications, readmission rates, and patient-reported outcomes were similar between both groups. The application of penile tourniquet during hypospadias repair can reduce operative time and the need for diathermy use; and also improves junior surgeon's satisfaction with intraoperative hemostasis without adversely affecting success rates or patient-reported outcomes.

Urological results and patient satisfaction in adolescents after surgery for proximal hypospadias in childhood

Proximal hypospadias repair is associated with a considerable complication risk. Long-term follow-up is required to present realistic expectations in pre-operative counseling. To investigate adolescents after childhood surgery for proximal hypospadias in a prospective cohort study describing the urological outcome, complication rates and patient satisfaction with penile appearance. 39 adolescents ≥14 years with penoscrotal to perineal hypospadias and primary urethroplasty (tubularized incised plate (TIP), preputial flap as Onlay or tubularized (Duckett)) from 1996 to 2005 at a single center were evaluated. The clinical assessment, at Md 16.5 years (14-25), included voiding history, genital examination including the Hypospadias Objective Scoring Evaluation (HOSE), uroflowmetry plus chart data from previous urinary flows and evaluation of patient satisfaction using the Penile Perception Score (PPS). Twenty-nine patients with penoscrotal and 10 with scrotal/perineal hypospadias underwent surgery with TIP (N=14), Onlay (N=14) and Duckett (N=11). Uroflows improved significantly compared with prepubertal maximal flows. Impaired flow rate (<10mL/s) was found in 14% (5/36). Fifty-one percent (20/39) required reoperations, 29% (4/14) of TIP, 50% (7/14) of Onlay and 82% (9/11) of Duckett (p=0.0062). Median penile length in adolescence was 8.7cm (4.0-11.0). Forty-four percent (12/27) of patients were dissatisfied with penile length. Patients were 'satisfied' or 'very satisfied' with meatal position and shape despite HOSE for meatal position being 11% (4/38) distal, 76% (29/38) proximal glanular and 13% (5/38) coronal. TIP patients had more curvature at puberty than Duckett (p=0.0062). Patients that had a decurvature procedure had shorter penile length (p=0.019). A high complication rate is previously described, predominantly within the first years. Our study shows 50% of reoperations were performed after >3 years, illustrating the need for long-term follow-up. Patient satisfaction with a deviant meatal position is rarely reported [1,2]. Our results support a conservative approach to an asymptomatic retracted meatus. Limitations of this descriptive study are the non-comparable groups and the retrospective data for correlation, impeding evaluation of prognostic outcome-factors. The shorter penile length found in patients after plication, and increased curvature after TIP, is therefore merely descriptive. However, the findings are in line with earlier publications suggesting limited use of TIP, and plication (recommending ventral lengthening instead) to avoid penile shortening and curvature in these cases [3-5]. The urological long-term outcome after proximal hypospadias repair is good, although late reoperations are common. In adolescence, patients were dissatisfied with the short penile length but satisfied with meatal position, indicating that in proximal hypospadias, preserving penile length and correcting curvature are prioritized over a distal meatus.

TIPU outcomes for hypospadias treatment and predictive factors causing urethrocutaneous fistula and external urethral meatus stenosis in TIPU: Clinical study.

Our aim is to present patient outcomes for the TIPU method, currently mostly used for distal and sometimes proximal hypospadias treatment, and to identify predictive factors for the most commonly encountered complications of this surgery of urethrocutaneous fistula and urethral meatus stenosis. TIPU is a versatile, reliable, cosmetic and functionally successful surgical method mainly used for distal hypospadias patients but also in recent times for some proximal hypospadias patients. The main complications are urethrocutaneous fistula, urethral meatus stenosis, glans dehiscence and urethral meatus dehiscence. The pre-operative anatomic features of patients were assessed with the glans-meatus-shaft (GMS) scoring. Post-operative assessment of surgical outcomes was performed with the hypospadias objective scoring evaluation (HOSE). The mean total urethrocutaneous fistula and meatal stenosis development rates were 20 (12.3%) and 25 (15.4%). Both complications were found to be significantly high among hypospadias patients with narrow urethral plate, flat glandular groove and small glans (p<.001). Multivariate binary logistic regression analysis found urethral plate, glandular groove and glans shape were predictive factors for fistula and stenosis development.

Modified Tubularised Incised Plate Urethroplasty (TIPU) with Dorsal Inlay Preputial Skin Graft: An Outcome Evaluation of 21 cases

There are different techniques of hypospadias repair, out of them TIPU is widely practiced and popular procedure. Here a midline incision is made over the urethral plate for widening of urethral lumen and creation of neomeatus. Meatal stenosis may subsequently develop at new meatus and it is the limitation of this procedure. In this study TIPU procedure is modified by applying preputial skin graft on incised urethral plate in dorsal inlay fashion and outcome is evaluated. In this prospective study total 21 patients with distal penile hypospadias underwent repair between 2016 and 2017. TIPU urethroplasty was done as usual along with application of a preputial skin graft on midline incised urethral plate. Tubularization was done over appropriate sized catheter and double layers bilateral Dartos flap was applied to cover the suture line. SPC catheterization was done in every patient. On 14th post-operative day urethral catheter was removed and on the same day if patient voids satisfactorily, SPC catheter was also removed. The outcome was evaluated according to the Hypospadias Objective Scoring Evaluation (HOSE) system. 95.23% of the patients achieved apical neomeatus and 90.47% of slit like meatal shape. Mild degree chordee and normal caliber urinary flow was in 9.5% and 95.23% of the patients respectively. 4.76% of the patients developed urethrocutaneous fistula. Dorsal inlay preputial skin grafting is a very simple and feasible technique to maximize the outcome of TIPU procedure. However, multicenter and high volume data are needed for its wide application.&#x0D; Bangladesh Med J. 2018 Jan; 47 (3): 9-12

Use of a Stent in Distal Hypospadias Repaired by Tubularized Incised Plate Urethroplasty: A Comparative Study

Purpose: We present our experience of stented and unstented distal hypospadias repaired by tubularized incised plate urethroplasty (TIPU). Patients and Methods: Data of 84 patients who were operated by TIPU method in 2 hospitals were retrospectively analyzed, and they were invited to be included in the study. Sixty-six patients agreed to participate in the study and were divided into 2 groups. Group 1 consisted of 38 boys operated in Sütçü İmam University Hospital on using a stent between 2015 and 2017. Group 2 consisted of 28 boys operated in Private Hospital of Megapark on without a stent between 2016 and 2017. The hypospadias objective scoring evaluation (HOSE) scale was used to compare the groups. Results: The median age was 2.81 years in group 1 and 1.95 years in group 2 (p = 0.243). The mean follow-up duration was 25.74 ± 4.62 and 24.5 ± 4.19 months in groups 1 and 2 respectively (p = 0.268). The HOSE scores were similar in both groups with comparable results (p = 0.622). Conclusions: No difference was observed between the groups in this study, regarding functional and cosmetic outcomes according to the HOSE score. However, the results should be supported by prospective studies with a sufficient number of patients.

Results of urethral plate preservation and use of vascular dartos flap in hypospadias repair

Background: Lower complication rates are observed if urethral plate (UP) is preserved and utilized for reparative surgery of hypospadias.Aim: This study aims to analyze our results of hypospadias repair by UP preservation, and using vascular dartos flap as interposition flap.Materials and Methods: prospective, cohort study of operated cases of hypospadias over 4.5 years' period. Data including age, diagnosis, preoperative testosterone administration, operation, postoperative complications, and assessment of outcome using hypospadias objective scoring evaluation (HOSE) system were collected. We preserved UP as far as possible, for urethral tube construction. We applied meatal advancement and glanuloplasty incorporated (MAGPI) for glanular/coronal hypospadias and tubularized incised plate urethroplasty (TIPU) (Snodgrass) for most other cases. Single dorsal vascular dartos-flap was transposed ventrally as interposition flap in TIPU. Single transurethral catheter 6F/8F size was employed as urethral stent as well as for bladder drainage. At the first review at 2 weeks after getting discharged, all patients underwent urethral calibration and first HOSE-score assessment. Maximum HOSE-score was 16 points and minimum 5.Results: A total of 111 patients with mean (range) age of 34.69 m (11 m– 123 m) were studied. TIPU (n = 49), MAGPI (n = 44), and others (n = 18) were the operations. There were 10 permanent complications; 9 following TIPU (7 (14.3%) single urethrocutaneous fistula (UCF), 1 torsion penis, 1 glans-dehiscence), and 1 following MAGPI (glans-dehiscence). Mean follow-up period was 15 m (range = 3–36 m). HOSE score ≥14 was achieved in 106 (95.5%) cases.Conclusion: The excellent result of MAGPI in our series is due to strict case selection and technical precision. UCF rate of 14.3% in TIPU can be due to the unselected nature of our cases which included small glans diameter and unfavorable UP characteristics.